Garden Healing Coper Marcus PDF

IDRP Interdisciplinary Design and Research e-Journal
http://www.idrp.wsu.edu/
Volume I, Issue I: Design and Health, January, 2007. Invited Essay: Clare Cooper Marcus
Healing Gardens in Hospitals

Clare Cooper Marcus is Professor Emeritus in the Departments of Architecture and Landscape
Architecture at the University of California, Berkeley. This essay is issued with the generous
permission of the author and NAI Publishers http://www.naipublishers.nl/architecture.html
For a patient, visitor, or member of staff, spending long hours in a hospital can be a stressful
experience. Nearby access to natural landscape or a garden can enhance peoples ability to deal with
stress and thus potentially improve health outcomes.
In past centuries, green nature, sunlight and fresh air were seen as essential components of
healing in settings ranging from medieval monastic infirmaries; to large municipal hospitals of the
17th and 18th centuries; to pavilion-style hospitals, asylums and sanitoria of the 19th and early 20th
centuries inspired by the work of public health reformer, Florence Nightingale.
From approximately 1950 to 1990, the therapeutic value of access to nature all but
disappeared from hospitals in most western countries. High-rise hospitals built in the International
Style resembled corporate office buildings; air conditioning replaced natural ventilation; outdoor
terraces and balconies disappeared; nature succumbed to cars and parking lots; and indoor settings
designed for efficiency were often institutional and stressful for patients, visitors, and staff. (Ulrich,
1992; Malkin, 1992; Horsborough, 1995).
The early 1990s, however, saw a reversal of this trend in the U.S., triggered by a movement
entitled Patient Centered Care. Hospital administrators became aware of negative reactions to the
prevailing institutional environments. Competition between hospitals fuelled a greater consideration

for patient needs. There was a slow shift away from the International Style to buildings designed in
regional context; to interiors that were welcoming and comfortable; to icons that were familiar (the
shopping mall, the home).
Significant research in the 1980s and 1990s brought support to what one might intuitively
believe to be so: that views to, or time in, nature have positive influences on health outcomes.
(Ulrich 1981, 1984, 1992; Hartig 1991, 1993, 1996). Consumer surveys of former hospital patients
differing by age, location and medical problem, found their most widely shared preference regarding
the physical environment of healthcare was for access to nature gardens, views, balconies, indoor
plants and nature pictures. (MacRae, 1997). Two studies which asked people where they chose to go
when they were feeling stressed or upset found that the majority chose to go outdoors to a natural
or designed setting. (Francis, C. and C. Cooper Marcus, 1991 and 1992).
The first systematic Post Occupancy Evaluation study of hospital gardens in the U.S. took
place in 1994 when four gardens in the San Francisco Bay Area were studied by means of visual
analysis, behavior mapping, and user-interviews. (Cooper Marcus and Barnes, 1995). People
appreciated traditional garden elements such as lawns, trees, flowers, and water features; ninety
percent of garden users experienced a positive change of mood after time spent outdoors.
Responses suggested that gardens were important because they represented a complete contrast to
the experience of being inside a hospital: domestic versus institutional scale; natural versus manmade; rich, sensory experience versus limited sensory detail; varied, organic shapes versus
predominance of straight lines; places to be alone versus few places of privacy; fresh air versus
controlled air; evoking links to the wider world of nature and the ongoing cycle of life versus
evoking thoughts of anxiety, illness, and death.

Typical responses from garden-users included:

My level of stress goes way down I return to work refreshed.
I sit in the garden before my appointment. It helps me deal with what they will
put me through.
I work in the Intensive Care Unit which is like a hell holeSitting here in the
sun is like therapy for me.
I work underground in the Radiation Department like one of the Mole People.
If I didnt have this garden to come tosunlight, fresh air, birdsong, treesI
think Id go crazy.
How do you feel after spending

time in the garden?
What is it about the garden that

helps you feel better?
More relaxed, calmer ...................79%
Trees, plants, nature ................... 59%
Refreshed, stronger.....................25%
Smells, sounds, fresh air ............. 58%
Able to think/cope ........................22%
Place to be alone or with friend ... 50%
Feel better, more positive ............19%
Views, sub-areas, textures .......... 26%
Religious or spiritual connection ....6%
Practical features, benches, etc. . 17%
No change of mood .......................5%
Dont know .................................... 8%
Responses from 143 garden users at four San Francisco Bay Area hospitals (Cooper Marcus,
C. and M. Barnes, 1995).
Other Post Occupancy Evaluations conducted around this time included one at a Childrens
Hospital in San Diego (Whitehouse, S. et al., 2001); one at a psychiatric facility in Canada (Perkins,
N., in Chapter 6, Cooper Marcus, C. and M. Barnes, 1999) and one comparing two small community

hospital gardens in Wales (Singleton, D., 1994). While none of these could prove that being in a
garden facilitates healing, where the question was asked: Do you feel any different after spending
time in the garden? ninety-five percent of respondents reported a positive change of mood. One
can reasonably assume that change to a more relaxed and calmer frame of mind is likely to enhance
the immune system and thus the body has a better chance of healing itself.
By the late 1990s, three books had been published in English on outdoor space in nursing
homes and hospitals (Cooper Marcus, C. and M. Barnes, 1999; Gerlach-Spriggs, N., R. Kaufman,
and S.B. Warner, 1998; Tyson, M., 1998); and several books were published on how to transform a
garden at home into a healing space (for example, McDowell, C.F. and T. Clark-McDowell, 1998;
Mintner, S., 1993). Patients and staff in hospitals were beginning to lobby for the creation of usable
outdoor space (for example, St. Vincents Hospital Cancer Center, Santa Fe, New Mexico; Good
Samaritan Hospital, Portland, Oregon); the American Society of Landscape Architects (ASLA)
began to sponsor special sessions on healing gardens at its annual conference. In 2003 the School of
the Chicago Botanic Garden initiated the first U.S. post-graduate course on Healthcare Garden
Design, training landscape architects who want to specialize in this field.
The Healing Garden: Essential Design Elements and Environmental Qualities

It is important to recognize that healing is not synonymous with cure. A garden cannot
mend a broken leg or cure cancer, but it can do the following:
Facilitate stress reduction which helps the body reach a more balanced state
Help a patient summon up their own inner healing resources

Help a patient come to terms with an incurable medical condition
Provide a setting where staff can conduct physical therapy, horticultural therapy, etc.
with patients
Provide staff with a needed retreat from the stress of work
Provide a relaxed setting for patient-visitor interaction away from the hospital interior.
Other terms used to describe such a garden are therapeutic, restorative, rehabilitative.
It is also important to remember that activities in healthcare outdoor space can range all the
way from completely passive to very active, for example:
Potential activities in a healing garden range from passive to active
Viewing garden through window
Sitting outside
Dozing/napping/meditation/prayer
Gentle rehabilitation exercises
Walking to preferred spot
Eating/reading/doing paper work outside
Taking a stroll
Child playing in garden
Raised bed gardening
Vigorous walking
Sports

To start to build a set of design guidelines for hospital outdoor space, one must begin with
Roger Ulrichs Theory of Supportive Garden Design. (See Ulrich, R., Chapter 2, Cooper Marcus, C.
and M. Barnes, 1999). In brief, this framework is based on the premise that gardens help to mitigate
stress to the extent that they:
create opportunities for physical movement and exercise
provide opportunities to make choices, seek privacy and experience a sense of control
provide settings which encourage people to gather together and experience social
support
provide access to nature and other positive distractions
In addition to these four basic guidelines, this authors observation of more than one
hundred hospital gardens in four countries (US, UK, Canada, Australia) suggests the need for
consideration of the following, if the garden is to be used and reach its full potential:
visibility
accessibility
familiarity
quiet
comfort
unambiguously positive art
1. Opportunities for movement and exercise

Exercise is associated with a variety of physical and psychological (i.e., stress-reduction)

benefits, including improved cardio-vascular health, and reduced levels of depression among adults
and children. (Brannon and Feist, 1997; Koniak-Griffin, 1994). The implications for healthcare
garden design include looped pathway systems offering a choice of shorter and longer routes;
settings which facilitate physical therapists to work outside with recovering stroke patients; settings
where well children can run and let off steam; places for contemplative walking (i.e., a labyrinth);
walking or jogging routes for staff on a break; corridors with views out to nature to encourage postsurgery exercise.
2. Opportunities to make choices, seek privacy, and experience a sense of control

On becoming a hospital patient, many experience a loss of control. It is often the institution
which decides what you wear, what you eat, when the doctor visits, etc. Stress stemming from lack
of control has been shown to have negative effects on immune system functioning and other
physiological measures among patients (Ulrich, 1999, p. 58), and decreased job satisfaction and
increased turnover among staff. Interviews with garden users suggest that regaining control and thus
reducing stress is one of the major motivations for garden use. (Cooper Marcus and Barnes, 1995).
Going outside is a means of escape. A patient reported: Its a good escape from what they put me
through. I come out here between appointments I feel much calmer, less stressed. (Ibid., p. 27).
For a garden to foster stress reduction by facilitating a sense of control, users must know it
exists, be able to gain access, and use it in the ways they prefer. Above all, the garden design must
offer choice places to be alone or with others; places to sit in the sun or shade, with an expansive
or close-in view; fixed and moveable seating; different walking routes all subtly reinforce a sense
of autonomy.

3. Settings which encourage people to gather together and experience social support
Research indicates that people with higher levels of social support are usually less stressed
and have better health than those who are more isolated, and that higher levels of social support
improves recovery or survival rates for various medical conditions. (Ulrich, 1999, pp. 42-5). Hence,
there is a marked trend towards longer visiting hours, social-support groups, and more attractive
waiting areas in hospitals.
The implications for gardens are to locate them close to patient rooms, waiting areas, and
hospital entrances; to provide sub-spaces so that small groups can find privacy; to provide moveable
garden furniture; and to provide some areas with outdoor tables and chairs so that a family or staff
group can have an informal meal together. A study of four California hospital gardens found that
staff were the largest users of outdoor space.
4. Engagement with nature

Nature attracts our attention without depleting the body of energy. A healing garden can
have the effect of awakening the senses, calming the mind, reducing stress, and assisting a person to
marshal their own inner healing resources.
For a garden to provide maximum therapeutic benefits, it needs to have a plentiful supply of
plant materials, some with distinctive seasonal changes; leaves or grass which move with the slightest
breeze; subtleties of color, texture, and leaf shape especially where frail people may move slowly
looking down or where people may sit for long periods in one setting. Plants may also be
experienced unconsciously as metaphors. Trees can provide metaphors of solidity, strength and

permanence; perennials of persistence and renewal; annuals of growth, budding, blooming, seeding,
decay, death and transformation.
A healing garden should also provide views to the sky and changing cloud formations; pools
that reflect the sky or trees and that can attract wildlife, reminding those in ill-health that life goes
on; elements that feature the sight and sound of moving water; and where possible, views to the
horizon or to borrowed landscape.
The layout of the garden should be such that walking or being pushed in a wheelchair
through the garden provides a variety of open and closed views, experiences of differing sub-spaces,
even elements of positive surprise or whimsy.
Our connection with nature in a garden can also be cognitive. The Healing Garden at Good
Samaritan Hospital, Portland, Oregon, provides plant labels which often engage peoples interest
and form triggers for conversation between patients and their visitors. (Cooper Marcus, C., 2003).
Architects and landscape architects need to work closely together to ensure that, as much as
possible, there are views out to gardens on the natural landscape from patient rooms, waiting areas,
staff offices, and corridors. Views out can also assist in way-finding thus reducing the stress of
finding ones way around a strange building.
Where there is no space on site for a garden or where the climate precludes the use of the
outdoors for much of the year, indoor gardens have been successful in providing access to natural
elements within a hospital building.
5. Visibility
In field observations at over one hundred acute care hospitals, only three included signs to

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an available garden, courtyard, or roof garden in their way-finding system. People have to know a
garden is there! Ideally, an outdoor space should be available at the building entrance, or visible from
the main foyer so that signage is not necessary.
6. Accessibility
People of all ages and abilities need to be able to enter and move around in the garden. Paths
must be wide enough for two wheelchairs to pass (minimum of six feet); they should be smooth and
wide enough for a patient on a bed or gurney to be wheeled into the garden; paving joints should be
narrow enough so as not to catch a cane, the wheels of a walker or an IV-pole.
In many hospitals visited, doors to outdoor spaces were kept locked to reduce use and
maintenance costs, or because staff were not close enough to monitor use. Accessibility can be
enhanced by ensuring that nursing stations have good visual access to gardens used by children, or
by frail or infirm patients; and that staff understand the therapeutic value of access to the outdoors.
7. Familiarity
When feeling stressed, many seek environments that are familiar and comforting. A
depressed person may be reluctant to leave their bed; an anxious person may seek the familiarity of
home. Similarly, those in medical settings who are stressed from overwork, illness, or anxiety need to
have access to garden settings which are soothing in their familiarity. This could mean an aesthetic
which is rooted in the culture of the majority of patients, spaces which are human- or domesticscaled; plants and furnishings that are familiar. These recommendations are especially important in
hospices for the terminally ill and facilities for people with Alzheimers disease.

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8. Quiet
If a garden is to have therapeutic value in a medical setting, it needs to be quiet a
complete contrast to the public announcements, TVs, and rattling trolleys of a hospital interior.
People using the garden need to feel a sense of calm, and to be able to hear birdsong, wind chimes,
or the sounds of a fountain. A study of four hospital gardens found that users were disturbed by
incongruent mechanical sounds such as air conditioners and street traffic. (Cooper Marcus and
Barnes, 1995). At the planning stage, it is essential that future garden spaces are located way from
traffic, parking areas, delivery driveways, and helicopter landing pads.
9. Comfort
Hospital patients often feel vulnerable. Patients who are elderly, infirm or mobility-impaired
need the reassurance of handrails, seating at frequent intervals (especially near the entry door), and
paving materials that do not cause excessive glare. Patients, staff and visitors also need to feel
psychologically secure: a garden space needs to feel and be safe, with some sense of enclosure and
the absence of feeling that users are in a fishbowl, being stared at. The degree of comfort in a
garden should be such that if they wish an ambulatory patient or staff on a break could
comfortably close their eyes or lie down in the sunshine for a nap. Some patients may be on
medications which require that they keep out of the sun; others may fear they will get chilled sitting
outdoors; some may have trouble getting up from a seated position. At the very least, a garden needs
to provide for physiological comfort with choices of places to sit in the sun or the shade; seating that
is protected from breezes by planting or structures; and bench seating which would allow someone
to sprawl or lie down, as well as garden seats with arms and backs.

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With the banning of smoking in most healthcare facilities, gardens and other outdoor areas
are being sought out by smokers. To avoid problems associated with second-hand smoke, smokers
need to be accommodated on a patio or other space separate from the garden used by non-smokers.
10. Unambiguously positive art

There is a human tendency when stressed to project onto nearby objects and people some of
the anxiety and discomfort experienced inside. Niedenthal et al. (1994) have developed the concept
of emotional congruence when a person is presented with an array of environmental stimuli,
those parts that match the emotional state of the viewer will most likely be the focus of attention.
Thus, abstract art that is seen as interesting or challenging by a non-stressed person may be
perceived as frightening or threatening by someone in a state of anxiety. (Ulrich, 1999, pp. 67-71).
Hence in a setting such as a hospital, known to elevate symptoms of stress, it is essential that art,
sculpture and other human-made design elements be unambiguously positive in their message.
Complex abstract art which may be appropriately challenging in a museum or corporate foyer is not
appropriate in a hospital. Research indicates that patients prefer familiar representational nature or
landscape themes and that patients recovering from heart surgery exposed to landscape photographs
of water and trees had lower anxiety and required fewer doses of strong pain killers than those in
control groups with no pictures. (Ulrich, et al., 1993). A classic case of the wrong kind of art
occurred in a US hospital where abstract figures of birds in a courtyard were viewed with dislike and
fear by cancer patients in adjacent wards, and eventually had to be removed. (Ulrich, 1999, pp. 7071).

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Precedents drawn upon by designers of contemporary healing gardens

Designers of healthcare gardens draw upon a number of different precedents to inform their
work. Some are successful, others less so. Few, so far, are evidence-based, yet many do seem to
provide successful therapeutic landscapes.
1. Archetypal spaces
2. Metaphors
3. Historical precedents
4. Domestic precedents
5. Regional attributes
6. Statement art
7. Medical diagnoses
1. The client and designer of the Therapeutic Garden of the Institute for Child and
Adolescent Development, Wellesley, Massachusetts, USA used the approach of creating archetypal
spaces such as a hill, cave, ravine, thicket, stream, bridge. The garden was created for the psychiatric
treatment of children who have experienced severe trauma. A recent book by the Director of the
Institute entitled Child Therapy in the Great Outdoors documents how children project their fears
and joys onto elements in the garden and are thus able to work through a healing process.
(Santostefano, S., 2004). Sad to say, due to the retirement of its director, this remarkable facility and
its garden are now closed.
2. A garden at Good Samaritan Hospital, Phoenix, Arizona, USA uses a metaphor of the Cycle

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of Life as a major theme in its design. A water course begins in a low fountain-pool, symbolizing
birth; it flows along a rocky course through the garden, symbolizing the passage of life; and ends in a
quiet, contemplative pool the end of life. While few users may consciously recognize the
metaphoric base of the garden design, the fact that there is a variety of still and moving water that
can be watched, heard and touched, as well as plentiful plant material and many choices of places to
sit, creates a well-used therapeutic milieu. (See case study in Cooper Marcus, C. and M. Barnes, 1999,
pp. 181-186.)
3. Designers of gardens and buildings often draw upon historical precedents. In the case of
healing gardens, some are more appropriate than others; some are good approaches for certain
populations but not for others.
The building-enclosed courtyard is an appropriate model as long as it is large enough and
adjacent buildings low enough that it receives sufficient sunlight, and as long as the privacy of
adjacent rooms is not intruded upon by people in the courtyard, or vice versa. The advantage of this
model in a hospital is that it is an enclosed, protected space; it is clearly hospital territory and
inpatients may feel comfortable sitting outside in hospital gowns. Some of the disadvantages are that
often the peripheral landscaping is poorly done (or totally forgotten) so that people avoid using the
courtyard as it is like sitting in a fish bowl. In addition, HVAC units are often placed in courtyards
intruding on the quiet that people seek in healthcare gardens.
The English Strolling Garden with lawns, flowers, trees and winding paths is a particularly
suitable historical model since it incorporates all four of the elements of Roger Ulrichs Theory of
Supportive Garden Design exercise, choice, social support, and nature distraction and is a
form familiar in many Western cultures. It is particularly appropriate in acute care hospitals and

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hospice facilities, enabling staff, visitors and ambulatory patients to escape to an environment in
complete contrast to the building interior. Some good examples include the AIDS Memorial Grove
in Golden Gate Park, San Francisco, California, USA; Houston Hospice, Houston, Texas, USA; The
Comfort Garden, San Francisco General Hospital, San Francisco, California, USA. (See case study
in Cooper Marcus, C. and M. Barnes, 1999, pp. 176-181.)
One of the oldest historical examples of healing garden design the medieval monastic
cloister garden has not, to the knowledge of this author, been used as a model in contemporary
healthcare garden design. It would be a particularly appropriate model in a chronic-care or geriatric
facility, with the roofed cloister forming a secure environment in which to sit, walk and view the
garden.
4. Domestic Precedents. Two forms of domestic precedent have been used successfully in
designing outdoor space in facilities for older people. In facilities where residents may be infirm but
are neither physically or mentally ill, a front porch or front garden is particularly appropriate.
Residents in nursing homes or senior apartments are not so much stressed as they are bored. Sitting
in a front-of-the-building location they can watch neighborhood activities, look out for a visitor or
the mailman, while socializing with fellow residents.
The outdoor space in a residential facility or day center for those with Alzheimers disease or
other dementias must be modeled on an enclosed back garden since such residents have a tendency
to wander. The enclosure of the garden (fence or wall) should be disguised by shrubs and trees so
that residents are not conscious of being fenced in. The back garden is also very appropriate as a
If a reader knows of a contemporary example, please get in touch with the author at clare@mygarden.com.

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model for a hospice where visitors and patients seek privacy and solitude in a setting which is
domestic and familiar.
5. Regional attributes. It is commonplace for a designer of a building to draw upon regional or
neighborhood context so that a new structure fits into its setting. It is not so clear whether a hospital
garden, similarly, has to draw on regional context. A roof garden at Harrison Memorial Hospital in
Bremerton, Washington, USA echoes the rocks and sparse vegetation of the shores of nearby Puget
Sound. A garden at San Diego Childrens Hospital echoes the colors and forms of a California beach
scene. Might the patients at both these facilities have preferred green, lush environments? We dont
know. Patients and visitors using the garden of the Houston Hospice appreciate the green, colorful,
shady setting even though it has little in common with the natural landscape of this part of Texas.
Clearly there is much that still needs to be researched.
6. Statement Art. While they are students, designers are often encouraged to create innovative
forms, breaking with former precedents. This goal is further encouraged in the professional world
where design magazines and awards tend to reward unique artistic statements that no one has ever
attempted before. This approach is not in and of itself wrong and may be entirely appropriate in
the design of, say, a new museum, concert hall, or memorial. But when this model is applied to a
healing garden, the results so far have been markedly unsuccessful in meeting the guidelines
suggested above. For example, an artist commissioned to design three hospital courtyards at the
West Dorset County Hospital, Dorchester, UK installed parallel rough stone walls that arc up out of
the ground and then disappear. The spaces have none of the attributes of a healing environment,
something recognized by the hospital staff who, in the years since construction, have brought in
flowers in pots and garden furniture to try and humanize these bleak spaces. Tilting slabs of

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travertine leaning rather ominously over a bleak, formal courtyard at the Cancer Clinic of Alta Bates
Hospital (Herrick campus) in Berkeley, California, USA do not create an environment for solace and
repose.
The above examples were created by an artist and an architect, respectively, pointing to the
importance of employing landscape architects who are trained to design gardens and other outdoor
spaces, and who have professional knowledge of plant materials. Such examples (which are not
unique) also remind us that when the term healing is used in the context of hospital gardens, it
obligates the designer to subordinate his or her aesthetic taste to the objective of creating userfocused, supportive environments.
7. Medical diagnoses. An exciting trend in hospital garden design is the provision of outdoor
spaces created specifically for the medical needs of patients and their caregivers. Gardens are
becoming the location of, and means of treatment for, certain patient groups.
(1) Rehabilitation Gardens. The Healing Garden at Good Samaritan Hospital, Portland,
Oregon, USA was designed with input from physical therapists, speech pathologists, and
horticultural therapists who work with patients who have had strokes or suffered brain damage.
Varied surfaces and slopes provide an arena for learning to walk again; varied planter edge heights
for sitting and leaning; a variety of labeled plants for color and shape recognition, reading, etc.
(Cooper Marcus, C., 2003).
At the Rusk Institute of Rehabilitative Medicine in New York City a play-garden for children
with brain injuries and mobility problems was designed with input from hospital staff, patients,
families and neighbors. With a range of topography, surfaces and features to manipulate, the garden
encourages physical activity, interaction with the natural world, the re-use of limbs, and taking risks.

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Activities which otherwise would have taken place in an equipped rehabilitation room now take
place outdoors with children hardly aware that they are exercising.
The Burn Center Garden at Legacy Emanuel Hospital, Portland, Oregon, USA is a unique
facility for patients and their families. Paths are wide enough for beds to be wheeled outside; grade
changes allow patients to practice walking; different textures to re-experience touch. Shade is an
essential element since it is painful for burn patients to experience direct sunlight.
The Serenity Garden at Scripps Memorial Hospital, San Diego, California, USA was
designed for a different kind of rehabilitation. Here patients enrolled in a drug and alcohol
rehabilitation program can use a mostly hardscape garden based on the 12 Steps Alcoholics
Anonymous model. A labyrinth in the center of the space is circled by twelve sub-spaces, each with
vegetation, a water or sculptural element, and inspiring words inscribed on a paving stone intended
to generate self-reflection.
(2) Gardens for patients with Alzheimers disease and other forms of dementia. More is known about
Alzheimers, its effect on cognition, and appropriate design responses than any other disease. (See
Zeisel, J. and M. Tyson, Chapter 9 in Cooper Marcus, C. and M. Barnes, 1999.) Among features
appropriate in a garden are a simple, looped pathway system with a single exit/entry door to the
building to help those who are spatially disoriented; features and plants that may evoke childhood
memories since long-term memory is less impaired than the events of today or yesterday; and nontoxic plant materials since at a late stage in the disease, people tend to put everything into their
mouths. Also important in such a garden, as indeed for all outdoor environments serving the elderly
are a trellis or porch at the entry to allow a gradual transition from indoor to outdoor light levels;
tinted concrete pathways to reduce glare (a problem for aging eyes); and low, intricate planting to

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engage the interest of a stooped, slow-moving person. (For case studies of excellent Alzheimers
garden designs see Cooper Marcus, C. 2005; Zeisel, J. and M. Tyson, Chapter 9 in Cooper Marcus,
C. and M. Barnes, 1999.)
(3) Gardens for patients with HIV/AIDS. The Joel Schapner Memorial Garden at Cardinal
Cook Hospital, New York City is a fine example of a formerly useless space a bleak rooftop on a
high rise building transformed by a sensitive designer (Landscape Architect David Kemp) into an
attractive green and colorful oasis for patients and staff. Special attention was paid to differing levels
of shade since patients on certain medications must not be in the direct sun; and to the provision of
planting containers for use in a horticultural therapy program. This space, formerly shunned because
of the negative association with AIDS, is now used by staff from all over the hospital and for fundraising events, while a leaf pattern featured on tiles in the garden has become the hospitals logo.
When the garden recently had to be reconstructed because of a leaking roof, current patients now
stronger and living longer because of new drugs asked for a space for weight-lifting in the garden
and a stage for karaoke singing.
(4) Gardens for cancer patients. Due to the cancer rates in many Western countries, cancer clinics
with adjacent gardens are becoming more and more common. A particularly successful example is
one at Mount Zion/University of California San Francisco Medical Center, where a formerly bleak
concrete courtyard was transformed into a healing garden by a breast cancer patient (who was also
an artist), along with a garden designer, and input from other patients. The garden incorporates
walking paths, the soothing sounds of water, engaging plant materials, places to sit alone or with
others and plenty of shade since patients on certain chemotherapy drugs must stay out of the sun.
Once the garden was completed, cancer patients and their families attended workshops where they

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inscribed their stories on tiles which now decorate the corridor overlooking the garden. (See Cooper
Marcus, C., 2001.)
A small, unpublished pilot study by this author with former and current cancer patients
revealed that their wishes for a healing garden (greenery, soothing sounds, shade, places of privacy,
etc.), and their concerns that certain elements not be present (intruding noise; too many hard
surfaces; steel, concrete or plastic elements, etc.) were no different from the preferences of hospital
patients in general with one exception. Patients on chemotherapy often feel nauseous when
exposed to strong smells. This suggests avoiding flowers with strong scents, and ensuring cooking
smells from a nearby cafeteria or restaurant do not drift into the garden.
Conclusions
There are many advantages to a hospital investing in a garden, which in relation to the
total cost of building and equipping a new facility is a very small amount.
Advantages to healthcare facilities

(Roger Ulrich, 1999)
Probably advantages:
Reduction of stress in patients, staff and visitors (very likely)
Reduced pain in patients (likely)
Reduction in depression (likely, especially if garden fosters exercise)
Higher reported quality of life for chronic and terminally-ill, patients (likely, especially if
garden fosters exercise)

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Improved way-finding (very likely, especially if garden in prominent location)
Potential advantages:
Reduced costs: Length of stay shorter for certain patient categories; fewer strong pain
medication doses
Increased patient mobility and independence
Higher patient satisfaction
Increased staff job satisfaction
Not only are there advantages for the patients, but also for staff working in stressful jobs,
under difficult conditions. With staff hiring and retention an increasing problem in many Western
countries, improving the work environment, including providing outdoor space for breaks, can be
an important investment.
Architects often think big via computer-drawn models and outdoor spaces are sometimes
seen as what separates buildings or whats left over. It is essential that a landscape architect be on
the design team from the beginning to guide site planning so that outdoor spaces are in appropriate
locations regarding access, micro-climate, etc.
Before the design of a garden reaches the schematic phase, it is essential that the design team
consult with medical staff likely to use the garden for outdoor therapy, and with potential patientusers. Ideally, the team should annotate the final plan with presumed health benefits so that a later
post-occupation evaluation study can be conducted to see if the garden functioned as expected.
Research results should be disseminated to peers, and information on garden benefits should be
disseminated to all current and future staff in a given facility so that they can encourage patients and

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families to make use of the garden.

Though we are becoming more informed regarding the benefits of healing gardens and their
essential design elements, there are still many unanswered questions.
Do people seeking calm and peace in a hospital garden prefer winding paths and an
organic layout, or a symmetrical design with straight paths so they can see their
destination?
Does it depend on the type of facility, the age of users, type of patient, the culture?
Do people find solace and peace in a Zen garden, or a paradise garden if they dont
understand its symbolism, or come from the culture of origin (Japan, Persia)?
Do cancer patients find comfort in a garden where the plants are those from which their
chemotherapy drugs are derived, or would they rather not be reminded when they come
outdoors to a healing place?
Do psychiatric patients, heart patients, and other patient-populations derive particular

benefits from healing gardens, and should designs differ for each group?
Do indoor and outdoor gardens facilitate similar stress-reduction benefits?
Do outpatients derive benefits from waiting for appointments in garden spaces?
How does a garden impact staff health and job satisfaction?
Do different garden elements or forms help alleviate different stress-related states (anxiety,
fear, depression, burnout, boredom)?
The healing garden is both a process and a place. It is a concept at the meeting point of
medicine and design. Some of the problems involved in the provision and retention of such gardens

23
stem from the fact that the medical profession thinks in terms of the internal process of healing but
barely recognizes the potential impact of the physical environment; while designers are familiar with
manipulating the elements of place, but sometimes overlook how these impact mood and behavior.
Clearly, continuing dialog and joint research between these professionals is called for.
While more research is needed, we cannot wait until every possible study is completed. The
evidence we do have warrants continuing efforts to establish healing gardens in healthcare settings
so that users may benefit and researchers have more real-life settings in which to assess their effects.
Like the medical profession, designers must become familiar with what is known up to this point, do
their best to remain true to these findings, and embrace the vow: First do no harm.

24
REFERENCES
Brannon, L. and J. Feist. (1997). Health Psychology, 3rd ed. Pacific Grove, CA: Brooks/Cole.
Cooper Marcus, C. (2001). Hospital Oasis. Landscape Architecture, October, pp. 36-41, 99.
Cooper Marcus, C. (2003). Healing Havens. Landscape Architecture, August, pp. 84-88, 104-109.
Cooper Marcus, C. (2005). No Ordinary Garden. Landscape Architecture, March, pp. 26-39.
Cooper Marcus, C. and M. Barnes. (1995). Gardens in Health Care Facilities: Uses, Therapeutic Benefits, and
Design Considerations. Martinez, CA: The Center of Health Design.
Cooper Marcus, C. and M. Barnes (Eds.). (1999). Healing Gardens: Therapeutic Benefits and Design
Recommendations. New York: John Wiley & Sons.
Cooper Marcus, C. and C. Francis (Eds.). (1998, second edition). People Places: Design Guidelines for
Urban Open Space. New York: Wiley.
Francis, C. and C. Cooper Marcus. (1991). Places People Take Their Problems. In J. Urbina-Sotia,
P. Ortega-Andeane, and R. Bechtel (Eds.), Proceedings of the 22nd Annual Conference of the Environmental
Design Research Association. Oklahoma City: Environmental Design Research Association, pp. 178184.
Francis, C. and C. Cooper Marcus. (1992). Restorative Places: Environment and Emotional WellBeing. In Proceedings of 24th Annual Environmental Design Research Association Conference. Boulder, CO;
EDRA.
Gerlach-Spriggs, N., R. Kaufman, and S. B. Warner. (1998). Restorative Gardens: The Healing Landscape.
New Haven, CT: Yale University Press.

25
Hartig, T. (1993). Nature Experience in Transactional Perspective. Landscape and Urban Planning.
Vol. 25, pp. 17-36
Hartig, T., A. Bk, J. Garvill, T. Olsson, and T. Grling. (1996). Environmental Influences on
Psychological Restoration. Scandinavian Journal of Psychology. Vol. 37, pp. 378-393.
Hartig, T., and G. W. Evans. (1993). Psychological Foundations of Nature Experience. In T.
Grling and R. G. Golledge (Eds). Behavior and Environment: Psychological and Geographical Approaches.
Amsterdam: Elservier/North Holland, pp. 427-457.
Hartig, T., M. Mang, and G. W. Evans. (1991). Restorative Effects of Natural Environment
Experiences. Environment and Behavior, Vol. 23, pp. 3-36.
Horsburgh, C. R. (1995). Healing by Design. The New England Journal of Medicine, Vol. 11, No. 333,
pp. 735-740.
Koniak-Griffin, D. (1994). Aerobic Exercise, Psychological Well Being, and Physical Discomforts
During Adolescent Pregnancy. Research in Nursing and Health, Vol. 17, pp. 253-268.
MacRae, S. (1997). Consumer Perceptions of the Healthcare Environment: An Investigation to Determine What
Matters. Preliminary report published by The Center for Health Design, Martinez, CA, andThe
Picker Institute, Cambridge, MA.
Malkin, J. (1992). Hospital Interior Architecture. New York: Van Nostrand Reinhold.
McDowell, C.F. and T. Clark-McDowell. (1998). The Sanctuary Garden. New York: Simon and
Schuster.
Mintner, S. (1993). The Healing Garden. London: Headline Book Publishing.

26
Niedenthal, P. M., M. B. Setterland, and D. E. Jones (1994). Emotional Organization of Perceptual

Memory. In P. M. Niedenthal and S. Kitayama (Eds.), The Hearts Eye: Emotional Influences in
Perception & Attention. San Diego: Academic Press, pp. 87-113.
Santostefano, S. (2004). Child Therapy in the Great Outdoors: A Relational View. Hilldale, NJ: The
Analytic Press.
Singleton D. (1994). Two Community Hospital Gardens: A Therapeutic Assessment. In M.
Francis, P. Lindsey, and J.S. Stone (Eds.), The Healing Dimensions of People-Plant Relations: Proceedings of a
Research Symposium. Davis, CA: Center for Design Research, University of California, Davis, pp. 269282.
Tyson, M. (1998). The Healing Landscape: Therapeutic Outdoor Environments. New York: McGraw-Hill.
Ulrich, R. S. (1981). Natural versus Urban Scenes: Some Psychophysiological Effects. Environment
and Behavior, Vol. 13, pp. 523-556.
Ulrich, R. S. (1984). View Through a Window May Influence Recovery from Surgery. Science, Vol.
224, pp. 420-421.
Ulrich, R. S. (1992). Effects of Interior Design on Wellness: Theory and Recent Scientific
Research. Journal of Healthcare Design, Vol. 3, pp. 97-109.
Ulrich, R. S. (1999). Chapter 2, Effects of Gardens on Health Outcomes: Theory and Research. In
Cooper Marcus, C. and M. Barnes. Healing Gardens: Therapeutic Benefits and Design Recommendations.
New York: John Wiley & Sons, pp. 27-86.
Whitehouse, S., et al. (2001). Evaluating a Childrens Hospital Garden Environment: Utilization
and Consumer Satisfaction. Journal of Environmental Psychology, Vol. 21, pp. 301-314.

27
Zeisel, J. and M. Tyson. (1999). Chapter 9, Alzheimers Treatment Gardens. In Cooper Marcus, C.
and M. Barnes. Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: John Wiley,
pp. 437-504.

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IDRP Interdisciplinary Design and Research e-Journal

Healing Gardens in Hospitals

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

Typical responses from garden-users included:

How do you feel after spending

What is it about the garden that

More relaxed, calmer ...................79%

Trees, plants, nature ................... 59%

Smells, sounds, fresh air ............. 58%

Able to think/cope ........................22%

Place to be alone or with friend ... 50%

Feel better, more positive ............19%

Views, sub-areas, textures .......... 26%

Religious or spiritual connection ....6%

Practical features, benches, etc. . 17%

No change of mood .......................5%

Dont know .................................... 8%

IDRP Interdisciplinary Design and Research e-Journal

The Healing Garden: Essential Design Elements and Environmental Qualities

Help a patient summon up their own inner healing resources

IDRP Interdisciplinary Design and Research e-Journal

Help a patient come to terms with an incurable medical condition

Provide staff with a needed retreat from the stress of work

Potential activities in a healing garden range from passive to active

Viewing garden through window

Gentle rehabilitation exercises

Walking to preferred spot

Eating/reading/doing paper work outside

Child playing in garden

Raised bed gardening

IDRP Interdisciplinary Design and Research e-Journal

create opportunities for physical movement and exercise

provide access to nature and other positive distractions

unambiguously positive art

1. Opportunities for movement and exercise

IDRP Interdisciplinary Design and Research e-Journal

2. Opportunities to make choices, seek privacy, and experience a sense of control

IDRP Interdisciplinary Design and Research e-Journal

4. Engagement with nature

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

10. Unambiguously positive art

IDRP Interdisciplinary Design and Research e-Journal

Precedents drawn upon by designers of contemporary healing gardens

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

IDRP Interdisciplinary Design and Research e-Journal

Advantages to healthcare facilities

Reduction of stress in patients, staff and visitors (very likely)

Reduced pain in patients (likely)

Reduction in depression (likely, especially if garden fosters exercise)

IDRP Interdisciplinary Design and Research e-Journal

Improved way-finding (very likely, especially if garden in prominent location)

Increased patient mobility and independence

Higher patient satisfaction